Green Doctor request for support - Groundwork by Groundwork
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Green Doctor request for support
GREEN DOCTOR
Get help
Green Doctor request for support
To see what free support is available in your area please contact us using this form.
Are you applying for yourself or referring someone else?
(Required)
Myself
Someone else
Where did you hear about this service?
(Required)
Let us know
GP or community social worker
Community event
Leaflet
Received a Winter Warm pack
Facebook
Twitter/X
Instagram
Google or other search engine
TV or radio
Title
(Required)
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev,
First name of person being referred
(Required)
Last name of person being referred
(Required)
Phone number
(Required)
Alternative phone number (i.e. mobile)
Email address
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Property tenure
(Required)
Choose your property tenure
Council leaseholder
Council tenant
Housing Association tenant
Private rented
Private owned
Unsure
Please tell us which of the following circumstances applies to you (if any)
Disability
Low income
Living with debt
Physical health issues
Mental health issues
Dementia
In emergency accommodation
Poor housing conditions
In receipt of benefits
Other circumstances, please explain:
Data Protection statement & consent *
(Required)
By ticking the box above you are agreeing and understand the information you supply will be shared with Groundwork. Groundwork will use the information you provide to confirm eligibility for the Green Doctor service and contact you to arrange an appointment, as well as for statistical and reporting purposes. Your contact details will not be shared with any other organisation without your consent or used for any purpose. If you are referring someone to the service you must have their consent to do so. By ticking above, you confirm that the person you are referring has consented to their details being shared.
